'Do the right thing'

Compliance is a term broad in scope, wide in meaning and deep in details. It is pervasive, encompassing the entire range of a long-term care facility's operations. And it should be something all operators want to do instead of something they feel forced to do, compliance specialists say.

Long-term care professionals are making significant strides in the establishment of proper policies, procedures and protocols. Compliance officers are becoming full-time, dedicated positions and they are leading the charge for better quality of care across the long-term care spectrum.

For instance, Keith Wolf, senior vice president and general counsel for the St. Barnabas health system in New York, is a prominent voice for the compliance officer profession. Though compliance can be seen as a complex issue, Wolf is able to break it down into its simplest form.

“Do the right thing,” he says. “When we do our training, we start off with what compliance means and that is to do the right thing. Whether you are a physician, nurse or housekeeper, you are a healthcare provider and your responsibility is to the patient.”

Compliance means living up to the trust that is placed on the provider community by the public, payers, government and all others within its sphere of influence, Wolf explains. It is a huge responsibility that he says must be paramount in the minds of everyone working in the industry.

“If Medicare or Medicaid is paying your facility to take care of their beneficiaries, their expectation is appropriate care, quality care and necessary care at the right level of billing for each patient,” Wolf says. “That should be reflected in your billing.”

Compliance is “a label for the activities that have always been there,” adds Deborah Brown, deputy general counsel at the Greater New York Hospital Association.

Adherence to the highest ethical, business and legal standards should start at the top and radiate throughout the organization, she notes.

“When top management really buys into it and shows it is truly committed by investing the necessary resources, it is a huge motivator for the staff to be a part of that team,” Brown says. “People need to know that they are accountable for all areas of their work, including patient care, billing and paperwork. They need to realize that every step they take has an impact.”

Every healthcare facility should have a compliance program in place, including a set of guidelines that serves as a blueprint. Brown cautions, however, that the guidelines should be more than a manual that is written and stowed on a shelf.

“It can't just be a program on paper — it needs to be a living, breathing entity,” she says. “It needs to be relevant and ongoing.”

As compliance officers have become more commonplace and empowered, Brown says they are gaining stature and in some organizations have been put in charge of a team of junior compliance officers and associates. As the compliance teams grow, they are getting more creative in conveying the message throughout their facilities, she says.

“You want people to understand that this isn't just about some cop who is laying down the law — it is about improving the quality of care.”

Compliance ‘everything'
Dana Penny is Chief Compliance Officer for Jewish Home Lifecare in New York and is responsible for three skilled nursing facilities in the metropolitan area. He has been with the organization since 1998 and has served in his current position since 2003.

Over that time, he has forged a solid compliance program that serves as a reliable touchstone for the entire operation.

“Just about everything brushes up against compliance,” he says. “It is my job to assess what is going on and find ways to improve our processes.”

One of the compliance officer's biggest challenges is keeping track of all the rules, which are constantly changing, Penny says. On top of that is a dramatic increase in audits for Medicare, Medicaid, pharmacy benefits and managed care.

“Any time regulations change, it could have implications for the business,” he explains. “For most providers, the biggest risk is not understanding the regulations and making mistakes because they are so complex.”

Setting priorities
With so many dimensions to compliance, those responsible for enforcement need to set priorities. At the top of that list, says Tamar Abell, president of Care2Learn/Upstairs Solutions, should be identifying and solving problems.

“The organization has to take a very close look at their internal audit system and ask themselves some tough questions,” she says. “These questions should include, ‘Are we finding our own problems?' ‘Are we correcting them?' And, ‘Are we ensuring that they don't happen again?' This is the true meaning of a quality assurance and training program.”

When it comes to priorities, Chip Kessler, the general manager of Extended Care Products, says that the compliance officer should focus less on specific rules and more on ingraining staff with the importance of standards.

“Yes, there are specific rules that must be followed and there can be no exceptions,” Kessler says. “However, no rule is going to be the determining factor as to whether or not staff members will follow proper procedures. Whether a facility can drive home the point with staff that every job is important will determine success or failure as a group.”

Chet Chandler, vice president of long-term care for MedAssets, says he understands the cost burden that compliance adds to a stressed budget, but he adds that operators need to be focused on the bigger picture.

“Compliance provides an opportunity to analyze existing operations and find better ways to provide quality care while saving money,” he says. “It requires all providers to review in a consistent and timely manner. It does add a layer of cost that is painful, but non-compliance hurts much worse.”
‘Muscle memory'
Compliance is the art of building “muscle memory” for an organization, where compliance officers serve as “personal trainers,” says Kathleen Chagnon, senior vice president and general counsel at Remedi SeniorCare.

“Building an effective compliance program requires an in-depth understanding of the facility's operations to identify where compliance exposures exist,” she says. “The compliance risks, and therefore priorities, can be different for each organization.”

The first challenge is documenting compliance policies and procedures, Chagnon declares. The act of documenting, she says, forces the organization to understand how the risk is being managed at the operational level.

“It ensures that the procedures are designed to integrate into the way we operate, rather than serve as rules that require unnecessary changes — which typically encounters resistance,” she says. “We emphasize the underlying regulatory concern or policy so that our employees understand the purpose of the policy and the risk that it is addressing. This seems to be working.”
Proper safeguards
Compliance officers need tools to exercise enforcement and ensure that rules are followed. Debi Damas, senior director for regulatory compliance and content for Silverchair Learning Systems, says the Quality Assessment and Performance Improvement (QAPI) programs should be an integral part of any organization's infrastructure. CMS released their “5 Elements of QAPI” last year.

“To be able to take a critical and honest look at the organization is the only way that true issues will be discovered and real improvements can be made,” she says. “Routine monitoring of systems, policies, and weak areas of an organization can lead to opportunities to re-educate staff so that if there is a deviation from what is expected from a regulatory and organizational perspective, things can be put back on track quickly.”

Effective communication between management and staff is a critical catalyst for delivering a consistent message, Abell adds.

“The message of what a corporate compliance program is should be the same for everyone, but the way it's taught and relayed to the staff can be very different for the CEO and the CNA,” she says. “The organization needs to make sure everyone is getting the appropriate training so they understand their role in the regulation and how they are tracking compliance.”

Ultimately, the facility that shows empathy with the staff and promotes a positive work environment will be successful in its compliance efforts, Kessler contends.

“You can put in place a program designed to punish the non-performers to the point where job loss is part of the picture and sometimes this is necessary,” he says.

“However, the organization that doesn't recognize the need for individual attention to staff needs and offer the proper training and re-training is going to suffer heavy turnover, and with it a reduction in quality customer service and job performance.”

SIDEBAR

Moving to a digital system

Providing a well-staffed environment is a cornerstone to compliance, but scheduling can be a thorny process — especially when done manually.

“Paper-based and partially automated scheduling make compliance with various regulations difficult and error-prone,” says Brian Graves, global practice leader for healthcare at Kronos. “Tracking staffing decisions is not easy, and often the real issue is there is no one place or real source of the truth where data can be found.”

“Visibility to schedules with staff-to-resident ratios helps administrators and nursing comply with staffing regulations around the clock while maintaining fiscal accountability,” he adds. “An automated system can provide visibility into the entire workforce so the right choices can be made, avoiding overtime and fatigue to existing employees.”